Intestinal Rehabilitation, Episode 3: Enteral Autonomy, Part 2

And we're back. We're continuing with part two of episode 3 of the intestinal rehabilitation podcast series where we're talking to Doctor Wales and Doctor Helmuth from Cincinnati Children's Hospital Medical Center. Last week, we left you on a little bit of a cliffhanger. Ellen, what did we talk about last week? In the first part, we were talking about enteral autonomy and adaptation. We talked about a bunch of different considerations including the anatomy and where you are in the bowel and what bowel you have left. We also talked about the importance of nutrition. And that's great because you need all that fundamental knowledge to get into the conversation this week where we start to talk more about therapy, surgical and otherwise. Hey, before we get into the episode, I want to remind you to register for our webinar on April 8th at 9:00 a.m. It's called The Best of the Best in Pediatric Surgery. We're gonna get Research presentations from all of the major pediatric surgery conferences of 2021. We're gonna give them to you in a condensed fashion in a few hours. It's gonna be awesome. It's gonna be fast. You're gonna love it. Registration link is below the media player. See you there. Let's get into the episode. Our selection of what we choose to deliver, whether it's, you know, elemental or semi-elemental or an intact macro module diet is important. Healthy eating and babies having oral eating skills is vitally important in the long term. You know, minimizing the amount of monosaccharides and the amount of hypotonic fluid that the child's drinking, if they have like a giginostomy, all these kinds of things like your nutritional choices are guided by your residual anatomy and how they're functioning. If they're not being provided adequate calories overall, then they're not gonna grow properly, they're not gonna heal properly. Their adaptive response is going to be diminished. So it's important not to, to give them inadequate parental support because you're worried about other complications developing. They need to be adequately supported. So, there's a fair amount of literature to suggest that the implementation of a feeding protocol in this setting, in this patient is associated with full autonomy in a shorter time period. Paper out of Boston, Chris Duggan's group published on this. As always, the article we're referencing here is linked below in the media player in the app. But the important thing is as a team to have an approach and a place to start and realize that these patients are all unique and we need to be flexible and, and individualize their care, even though we have in our head guiding principles that sort of help guide our decision-making. So there are a lot of decisions that a surgeon makes that will influence the next couple of months in the These kids, and so obviously, the surgery needs to be set up so that the next surgery is not a big laparotomy if you need to. Understand, the bowel heals with adhesions, that brings in blood supply to the bowel that helps it heal. Feeding access options include feeding through a mucous fistula, but these can be really challenging to manage. Strategies that give you access to the stomach early are helpful. The idea sometimes. And just putting a tube in the stomach at the time of surgery that is beyond the pylorus and letting the NG decompress the stomach and that be a refeeding tube that later is changed out to a gastrostomy tube has been a benefit we've seen here. Stoma placement is hugely important. Refeeding in our hands is done best through a tube. And at Cincinnati Children's, we have a document about how these feeding tubes are placed and how they're used, and we'll link it below. It allows the nurses to. Feed in a very standardized way which has proven to be very simple and easy. And although yes, tubes get clogged and displaced, overall, far less, more challenging than I've experienced with people who use mucous fistulas. The point is that the approaches we make surgically at the time play a huge role in the initiation of feeds. The last thing I will let people know is that you can have very high outputs initially in damage. Bowel that requires luminal nutrition to start getting the bowel to learn how to reabsorb fluid. High outputs without feeding are an indication to feed, as long as the child can be hydrated, and that is also a clinical conundrum that can be very challenging at the bedside. As a surgery resident, I feel like we're always worried about postoperative input output numbers for the surgical patients. Let's say hypothetically, the stomach is making too much fluid. There's too much output. How do you manage that? That's a challenging problem. I mean, sometimes, like early on, after some of it's physiologic, that high those high gastric losses, um, after a massive resection and the loss of distal bowel and the loss of sort of feedback, hormonal messaging, you can be hypergastronemic and therefore have elevated acid secretion for a period of time. Like the books will say anywhere from 6 to 12 months. So, one way to decrease gastric volume in the short term is to block The with some kind of acid blockade, uh, whether it's an H2 blocker or a PPI. If the child isn't tolerating feeds and has high gastric output, what does that mean? Or what do we do about that? There is a counter side to that and the impact on the risk of, you know, bacterial overgrowth and things like that by losing that acid barrier. That's one mechanism. Prokinetic therapy is another mechanism to try to improve gastric emptying and, and motility if someone is dysmotile, and, you know, your options there are intravenous agents, whether it's Metoclopramide or erythromycin or something like that, or enteral agents like domperidone or cisapride and pass the stomach, whether that's like a, a duodenal or jujunal tube, nasal gastric. Use an NJ tube or a GJ tube even to kind of get past. Right, and then you can pass the tube in the stomach to vent the stomach and relieve the pressure there. But deliver nutrition beyond the pylorus and, and get the calories in downstream. Increased secretions is because you have a thick, leaky mucosa, and the way to sort of improve that is to heal that mucosa, and that requires the delivery of luminal nutrients. This is a very complex balance of hydration and nutrients and depending on where you're talking about in the anatomy. So for Dr. Helmrath, it all comes down to biochemistry. So everyone looks at cc per kilo out, which could be much more than 40, 50, 60, and everyone gets uptight. But if you're following the bicarb and it's above 20, I Believe you're generally you're OK. You can have some acetate in your TPN and you can hydrate the child, and if you keep that, that bicarb over 20, feeding, I think is safe. So, that's a number you should keep your eye on, and let that guide you. Aside from just these nutrients and fluids that we're giving, these patients are complex and they're also getting a lot of medications like antibiotics. You know, there's enteral antibiotics, cycled antibiotics for the treatment of bacterial overgrowth, which is often done very empiric and ad hoc. Anti-secretory or anti-diarrheal medications, whether that's things like octreotide or clonidine or loperamide or, you know, these kinds of things to decrease losses, if you will. The motility drugs we've talked about. So, this part is trial and error. You have to talk to your team. You have to have an approach that's tailored specifically for this patient. And then if this fails, we're gonna do this instead and, and you move down the line in a methodical way so that you know what works. And what doesn't work for that patient. So I do believe there is a role for pharmacotherapy, but you can get the same approach by thoughtfully refeeding. And we have to understand what we're treating. If the child is sick, don't dip the baby in antibiotics for two weeks. If the baby isn't showing you clinical signs, have definitions of how long you're treating endpoints. Let's talk about surgery and how it can be used as a tool to promote adaptation and And these guys like to break it up into three categories. There are procedures to restore continuity, so patients that have a stoma and enclosing the stoma immediately recruits more bowel, generally, right? Patients that have strictures or adhesive obstruction or whatever like that. The first category was about restoring continuity. The next category is a procedure that will help affect motility. And motility can be too slow or motility can be too fast. Generally speaking, in this population. We're talking about dysmotility where it's too slow and we often see that in the setting of a dilated loop of bowel, which sometimes is being driven by a distal partial obstruction, um, and so you gotta fix that obstruction. But as that bowel becomes increasingly dilated, its motility becomes impaired. So when you have an obstruction like this, you'll have a loop of bowel, the stool isn't moving, then you get mucosal inflammation there. That mucosal surface will then become raw, and then you will have damage to to the mucosal barrier that allows bacteria to pass freely and then the child can become septic and then you have malabsorption. In theory, if you could restore the caliber of that bowel to something more normal, then you get improved motility, better clearance of stool, decreased overgrowth, the mucosa starts to heal, and then absorption to function improves. So, you know, you could, you can taper the bowel on the anti-mesenteric side. You can resect the, you know, that segment that's quite dilated if you feel that the patient has sort of adequate length. And so we talked about restoring the continuity of the bowel, we talked about the motility of the bowel, and the last category are procedures to lengthen the bowel. Traditionally, that would include the Bianchi procedure, the longitudinal intestinal lengthening procedure, which has been around for a lot longer, like since 1980, versus the serial transverse enteroplasty. Probably one of the most important factors of both of those procedures as far as efficacy goes is really you're tapering the bowel. What's different about a step versus an anti-mesenteric tapering or resection is that you're preserving all of the available mucosa. You're not removing any mucosa. So, in a person who is quote unquote, shorter with a dilated segment and you don't want to take anything out, a step becomes an option or a Bianchi becomes an option to preserve all the available mucosa, but still deal with the, the dilated segment, if you will. And there's a lot of controversy about the role of these procedures, and I know there's patients that I I did then that I wouldn't do now. How you're gonna use surgery to sort of improve function, and that should be part of, that should be a team decision. So here we're talking about a high-level overview of these procedures. In one of our future episodes, we're actually gonna go deeper on these bowel lengthening procedures and some of the surgical procedures for these patients. Basically, improving contact with, with the available mucosa, you will have some ongoing dilatation of that bowel, and the bowel will continue to grow because it's an infant or a young child. Then you actually have more surface area, if you will, because of those downstream adaptive responses. The key thing to realize about these procedures is that you're not really increasing the surface area, you're sort of redistributing it. So it should take about 6 months to see any changes in the absorption. We published that experience several years ago looking at absorption studies, fecal fat and uh alpha-1 antitrypsin clearance, and xylose as a measure of macronutrient absorption and Citrulling rise and things like that over time, you have to be patient. So there are 2 things they want you to know here. One is decision making, and so, not knowing the natural history and the progress of your patients, how do you know when to intervene and to decide one of those questions? And number 2 is that an upper GI can only rule in a problem. It does not rule out a problem. And so many people are comforted by an upper GI move. If the upper GI is making a decision, you're gonna be acting way too slow. A normal upper GI does not rule out an anatomical problem. OK, so there you have it. Our 3rd episode in our series on intestinal rehabilitation. It's a complex concept that necessitates understanding of biochemistry. You have to understand the function and anatomy of the different parts of the bowel. The definition of ventralal autonomy has changed. With the new aspen guidelines, now. Say autonomy is the independence from parental support for 12 weeks, and the interventions we use to assist with internal autonomy in babies depends on the reason for the underlying etiology of the issue in the first place, but it can include things like nutrition with TPN. It can include other medications and treatments such as antibiotics and kinetic. Agents and then surgery can act as a method to redistribute or increase the bowel surface area. Whether you're listening to this podcast on your way to work or on the way home from work, we know that you're busy taking care of patients and you probably were so busy that you couldn't go to every pediatric surgery conference that you wanted to this year. But don't worry, we have a webinar coming up for you. It's called The Best of the Best in Pediatric Surgery. Ellen, when is it? Happening on Friday, April 8th in the morning at 9:00 a.m. Eastern Standard Time. So if you want to register, guess what? Registration is free, it's open. There's a link under the media player. Sign up today so that you don't miss the best research from every pediatric surgery conference of the past year. Right here on your phone, on your tablet, on your computer, wherever you are. But until then, I'm Rod and I'm Ellen. We're research residents at the Cincinnati Children's Hospital, and remember, knowledge should be free.